[Experiences with ambulatory arteriovenous shunt surgery. A cost-benefit analysis]

Placement of arteriovenous (av) fistulas has been executed at the reporting surgical department for 3 years. Calculation of the reimbursement by the insurance companies is based on the so-called "Unique Evaluation Table" (Einheitlicher Bewertungsmassstab). The aim of the study was to evaluate the efficiency of the placement of av fistulas in an out-patient setting and the acceptance of this approach in the patients. The costs based on an average of the duration of the intervention and treatment at the out-patient clinic per time unit for surgeon, nurse and operating room, as well as costs for use of specific materials were listed, summarized, and compared with the amount of money which was reimbursed by the insurance companies according to the "Unique Evaluation Table". During the 3-year time period, 67 patients underwent 70 placements of av fistulas in an out-patient setting (in total, 532 interventions). Patients answered a questionnaire, and procedures were evaluated for average costs. Based on the table-dependent reimbursement of DM 274.00 (according to the "Unique Evaluation Table"), costs of DM 497.94 (DM 445.50 for 54 min of mean duration of surgical procedure plus DM 52.44 for materials) were determined, indicating that no full reimbursement was found despite the fact that there was only a minimal rate of early complications (thrombosis, n = 2 [3%]) (infection, n = 1 [1.5%]). The expenses were 81.7% on average above the level of the reimbursement. In conclusion, despite high acceptance of an out-patient setting for placement of av fistulas in patients (82%), it is not efficient from an economic point of view and can be only provided for specifically selected cases. Therefore, it is not advisable at present to place av fistulas at German out-patient clinics with no following admission of the patients, to avoid financial disadvantages for the surgical department. New negotiations between the medical profession and the insurance companies are urgently needed to ensure an improved financial outcome for the clinics.